Summary & Overview
CPT 57289: Repair of Cystocele and Stress Urinary Incontinence, Vaginal Approach
CPT code 57289 denotes a vaginal surgical repair that treats both a cystocele (anterior vaginal wall prolapse) and stress urinary incontinence in a single operative session. Nationally, this code captures combined pelvic reconstructive and anti‑incontinence care delivered via a vaginal incision, a common approach in urogynecology that can affect utilization patterns, surgical setting choices, and payer coverage decisions. Key payers addressed in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.
Readers will gain a concise overview of the clinical context for CPT code 57289, typical sites of service, and the combined nature of the repair. The publication summarizes benchmarking data and payment considerations across major payers, highlights relevant coding and billing practice points, and outlines where policy updates or coverage rules may influence clinical workflow and reimbursement. The material is intended to inform billing managers, surgical providers, and policy analysts about how this code is used, common settings for service delivery, and what to expect in payer interactions at a national level. Data not available in the input is noted where applicable.
Billing Code Overview
CPT code 57289 describes a surgical procedure that addresses both a cystocele (anterior vaginal wall prolapse) and stress urinary incontinence by repairing the vaginal wall through a vaginal incision. The procedure combines pelvic reconstructive techniques to restore normal anatomic support and reduce urinary leakage associated with stress incontinence.
Service Type: Pelvic reconstructive surgery combining cystocele repair and anti‑incontinence procedure
Typical Site of Service: Hospital operating room or ambulatory surgery center, performed via a vaginal approach
Clinical & Coding Specifications
Clinical Context
A typical patient is a postmenopausal or multiparous woman presenting with symptomatic pelvic organ prolapse characterized by anterior vaginal wall descent (cystocele) and concomitant stress urinary incontinence. She reports urinary leakage with cough, sneeze, or exertion and pelvic pressure or a vaginal bulge that interferes with activity. Prior conservative measures (pelvic floor physical therapy, pessary) were attempted or are declined.
Preoperative evaluation includes a focused history and pelvic exam with POP-Q assessment, urinalysis to rule out infection, post-void residual measurement, and counseling regarding risks and benefits. Shared decision-making determines a vaginal approach; the surgical team schedules a transvaginal anterior repair with an anti-incontinence procedure through the vaginal incision. The patient receives general or regional anesthesia and perioperative antibiotics per facility protocol. Intraoperative steps include anterior vaginal wall incision, dissection of the vesicovaginal space, removal of redundant vaginal mucosa, plication of pubocervical fascia to reduce the cystocele, and a concomitant procedure to address stress urinary incontinence (such as a sling or midurethral support inserted through the same incision if applicable). Hemostasis is secured and the vaginal epithelium is closed.
Postoperative workflow includes routine PACU recovery, analgesia, voiding trial prior to discharge, and instructions on activity restrictions, wound care, and follow-up for suture removal and evaluation of continence and anatomic result. Complication surveillance includes monitoring for urinary retention, urinary tract infection, wound separation, and persistent or recurrent prolapse or incontinence.
Coding Specifications
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